Please note, failure to obtain authorization may result in administrative claim denials. IlliniCare Health providers are contractually prohibited from holding any member financially liable for any service administratively denied by IlliniCare Health for the failure of the provider to obtain timely authorization.

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As the Medical Home, PCPs should coordinate all healthcare services for IlliniCare Health members. Paper referrals are not required to direct a member to a specialist within our participating network of providers. All out of network services (excluding ER and family planning) require prior authorization. PCPs should track receipt of consult notes from the specialist provider and maintain these notes within the patient’s medical record.

Some services require prior authorization from IlliniCare Health in order for reimbursement to be issued to the provider. See our Prior Authorization List, which will be posted soon, or use our Prior Authorization Prescreen tool.

Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.

Authorization requests may be submitted by fax, phone or secure web portal and should include all necessary clinical information. Urgent requests for prior authorization should be called in as soon as the need is identified.

IlliniCare Health’s Medical Management department hours of operation are 8 a.m. to 5 p.m. Monday – Friday (excluding holidays). After normal business hours, NurseWise staff is available to answer questions and intake requests for prior authorization. Emergent and post-stabilization services do not require prior authorization. Urgent/emergent admissions require notification within two (2) business days following the admit date.

We will process most routine authorizations within five business days. If we need additional clinical information or the case needs to be reviewed by the Medical Director it may take up to 4 calendar days to be notified of the determination. Authorization determinations may be communicated to the provider by fax, phone, secure email, or secure web portal.